Examination of Witnesses (Questions 1-19)
10 MARCH 2005
MS ELAINE
MCHALE,
MS CATH
ATTLEE, MS
YVONNE COX,
MR MICHAEL
YOUNG AND
MS DENISE
GILLEY
Q1 Chairman: May I welcome you to this
session of the committee at the start of a short inquiry into
continuing care. We have three separate short sessions this morning.
As we are trying to get through so many witnesses and questions,
may I ask colleagues to be brief and witnesses be reasonably concise.
May I thank you for your written evidence. Would you briefly introduce
yourselves to the committee.
Ms Gilley: I am Denise Gilley,
Policy Leader for Older People at County Durham and Tees Valley
Strategic Health Authority.
Ms Cox: I am Yvonne Cox, Chief
Executive from the Oxfordshire Learning Disability Trust.
Ms Attlee: I am Cath Attlee, Director
of Commissioning & Modernisation at Hounslow Primary Care
Trust and Chair of the North West London Continuing Care Review
Group.
Mr Young: I am Michael Young,
a development manager for partnerships at North West London Strategic
Health Authority.
Ms McHale: I am Elaine McHale,
Director of Social Services for Wakefield, but representing the
ADSS and LGA.
Q2 Chairman: May I begin by just exploring
the issue that we, the committee, come back to in almost every
inquiry that we do that relates to social services and health,
and that is boundaries. Obviously the boundary is at the heart
of much of what we are going to be talking about this morning.
I have a clear recollection of Frank Dobson in front of the Committee
when we were having an inquiry into the relationship between health
and social care and the division between the two. I asked him
if he could give us a definition of the division between health
and social care. He said that he honestly could not. That was
probably five or six years ago. Are we any nearer establishing
a division? Can anybody give me a categorical division between
the two areas?
Ms Gilley: I think we are nearer
but I do not think, unfortunately, unless one of my colleagues
is about to volunteer, any of us could give you a categoric definition.
Much of that is based on the needs of individuals, which will
differ. If you are going to take account of those on the one side,
which is what we are trying to do currently, and you have a very
tight definition, that will exclude some people who otherwise
should be funded by the NHS.
Ms Attlee: As policy and practice
change, the boundaries are shifted, so we are looking more and
more at different professionals taking on different skills and
mixing those. It is not helpful to define things specifically
as a health input or a social care input. We are looking more
and more at being able to provide complex packages of care by
a range of professionals. In some ways, the policy here is a little
behind the practice around that developing role.
Ms McHale: I would like to echo
what my colleagues have commented on there and the fact that we
do have to modernise this criteria and guidance to reflect the
aspirations of policy between both health and social services.
That is potentially slightly easier to define but potentially
restricts what social services do because of the different statutes
available.
Q3 Chairman: One of the issues we have
talked about on many occasions is removing completely the definition
of a boundary. If that were to happen, would it not make your
work a good deal easier? I am struck that when we are told to
remove that boundary, inevitably Treasury have to move one way
or another, either to introduce charges to the NHS for what is
currently free care, or to remove means-tested social care charges,
which would be tough for any government to do. If one looks at
the cost of what I regard as an industry around the division between
the health and social care of people on both sides of the fence
attempting to make sense of something that, frankly, is not sensible,
would we not save a substantial amount of money? Has the amount
of money that would be saved around the margins by abolishing
this division ever been calculated?
Ms McHale: There is an element
of truth in that. There is lot of public funding being spent on
legal definitions, particularly around this policy guidance, and
much wasted time and energy in trying to achieve an outcome for
individuals in different local authorities. Fundamentally, there
is a lot of unmet need here as well in terms of the application
of continuing care. I do not think this is properly resourced.
Whether there is sufficient to be able to get it out of what is
going into the legal challenges or the differences of opinion
is potentially a bit underestimated.
Q4 Chairman: Has anybody in an organisation
like yours that has obviously been involved in this issue for
a long time, the ADSS, along with, say, the NHS Confederation
or somebody who has a role in health actually looked at an estimate
of the costs of abolishing the charges on the social care side
and balancing that against the current costs of policing this
division about which none of us feel able to come up with a definition?
Ms Gilley says we are getting near it. I can recall getting near
it 25 years ago but we are still not there. Has the ADSS made
an estimate or a guesstimate of this?
Ms McHale: I cannot honestly say
that anyone has attempted to guesstimate. I would like to add
that as there is closer movement towards what health and social
services do, that means some things have been lost in what social
services have done previously. That is potentially around the
prevention agenda and the domestic/domiciliary aspects of enabling
people to live independently. These things are not calculated.
Ms Gilley: The nearest you would
be able to come to it, and it was some considerable time ago (not
quite as long ago as 25 years, you will be pleased to hear) is
the Royal Commission into Long Term Care, which did quite a lot
of work in calculating various scenarios. It would be possible
to extrapolate some of the information from that. The amounts
were hugely significant to the Treasury.
Q5 Chairman: It is fair to say that the
cost of policing this divide is a very sizeable amount of money,
is it not?
Ms Gilley: Yes, but you would
have to extrapolate the figures from the Royal Commission and
then perhaps look at one local area and extrapolate from that.
If you multiply by 28, for instance, that would give some order
of magnitude of one to the other.
Ms Attlee: This is an important
calculation that needs to be done. It would be increasingly difficult
to do. Certainly, in the way in which we have assessed and gone
through the process of assessing people's needs for continuing
care, we have tried not simply to focus on what is the financial
responsibility but to look at how we use this process to ensure
that care needs are appropriately met. We are disentangling the
policing and financing issue from doing a proper assessment. Finding
the appropriate care package would be quite difficult on the costing
elements. That bit around doing a multidisciplinary assessment,
recognising the appropriate needs and how we meet those in a care
package would still need to be done, whether or not it was met
through fully-funded NHS care or through a local authority funded
package.
Q6 Chairman: One of the issues we have
picked up in evidence we have received is the impact of different
eligibility criteria. Ms Gilley suggested that in looking at costings,
you could look at one area and extrapolate from what is happening
in one area what a national cost might be. One problem with that
is that we hear the situation is different from area to area.
Can you give us examples of some of the difficulties that perhaps
you pick up with different eligibility criteria when you work
physically across boundaries?
Ms McHale: I have led a group
of West Yorkshire local authorities and we have agreed the eligibility
criteria with the strategic health authority. We believe we have
a good partnership approach to its implementation. However, there
are differences in its application, even though the eligibility
is the same. We have pulled a group of representatives from both
health and social services together to look at cases every now
and again to see why in Bradford you might get continuing care
with this case but, if you applied for it in Wakefield, you would
not. There are still difficulties with the same eligibility criteria
and the same enthusiasm to implement that; there are differences
of outcome.
Q7 Chairman: Be careful how you answer
this next question because it might land on your desk. I can think
of a particular case I am dealing with where a Wakefield resident
has gone to Barnsley, which is in a different SHA where presumably
the organisation is somewhat different?
Ms McHale: That is interesting
because payment by results is going to make this even more difficult.
Q8 Chairman: Can you say a bit more about
that?
Ms McHale: Yes. Payment by results
is going to mean a transfer of cases across a wider range of providers.
You can get the first assessment of continuing care in an acute
hospital. You will be asking staff potentially to work against
different interpretations of continuing care criteria for any
amount of patients coming in from different locations. Potentially,
it will become even more difficult for people to accept continuing
care by that change in policy alone.
Q9 Chairman: The choice agenda has a
huge bearing on this?
Ms McHale: It does, and the modernisation
of this policy has to take account of these new policies that
are coming in, too. The same would apply to the impact on direct
payments under Section 117.
Ms Attlee: It is worth pointing
out that however clear the national framework was or a local framework
is, there will always be an element of professional judgment.
We have discovered, in terms of trying to eliminate the inequitable
impact, that it is about putting in a system with the checks and
balances. You have a multidisciplinary team doing the assessment;
another multidisciplinary panel validating that assessment locally;
and then a strategic health authority-wide or higher level authority
validating across the board, so that you are constantly doing
that cross-checking. You are not going to eliminate the element
of professional judgment, even if you have standard criteria across
the country. Every clinician will interpret slightly differently,
and practice is changing all the time. You need constantly to
be validating against that new practice. It is important that
in any system we implement you build those checks and balances
in. One of the advantages of the latest criteria on implementation
has been in allowing us to recognise that and to establish those
mechanisms jointly with local authorities, so that we are together
validating on a regular basis. That needs to be built into the
system throughout, preferably involving users in the voluntary
sector, so that we are getting that validation throughout the
system, not simply through the statutory bodies.
Q10 Chairman: Do you think that with
the development of common single assessment processes there is
now much greater understanding between professionals as to what
the criteria are? Where criteria are established, is there a greater
ability to get to an agreement on the criteria or whether someone
satisfies the criteria? Has that improved?
Ms Attlee: Yes.
Ms Cox: I was reflecting on some
of your earlier questions and answers. In looking at learning
disability services, which in many respects have been at the forefront
of much of this work, 10 or 15 years ago we were used to having
the money put together. There has been general acceptance of a
multidisciplinary/multi-agency approach in terms of the assessment
of people's needs and how those needs on an individual basis can
be met. It is important that as we develop new guidance that is
picked up. It is not just about continuing care for older people
but for all of the population. There are probably some models
around in groups of people that may be smaller per head of population
but are equally important. I think the single assessment process,
which we are now seeing in children's services and for learning
disability and so on, begins to iron out some of these things.
That would undoubtedly give a better consistency and level of
understanding by everybody.
Q11 Chairman: I was struck by a comment
that Anne Abrahams, the Health Services Ombudsman, made to one
or two of us who met her recently. She said that the professional
joint working, currently common practice in most areas, left departmental
demarcation lines behind it many moons ago. Is this not an area
where the demarcation lines are grossly outdated and it would
help you people if those demarcation lines—and I can be
repetitive and boring on this subject, as I have been for nearly
eight years on this committee—were abolished and we moved
forward without that problem? Would that not be extremely helpful
in moving forward in the future?
Ms Cox: I think it would be helpful
if you look at the Cabinet Office document January 2005, Improving
The Life Chances For Disabled People and the view for provision
for that over the next 25 years. That is broader than simply health
and social care. That would embrace education, the benefits agency
and so on. The vision behind that around individualised funding,
using direct payments and a variety of other methods would seem
to indicate a very different and better way forward, leading on
from the issues of choice and all the things that the NHS has
done, but linking into other mainstream policies around social
care—housing and so on.
Q12 Dr Naysmith: On this subject, it
might be useful to ask Ms Cox at this stage: do you think we should
have separate criteria for different client groups? I know you
said that the older ones are much larger in numbers than some
of the others. Do you think that would be the right thing to do?
Ms Cox: Personally, I think that
the criteria, particularly for adults, does need to be different.
We piloted a modified system from Thames Valley recently. I am
struck by the emphasis on what people cannot do. The whole issue
around learning disabilities, certainly in Valuing People
(DH March 2001) and Improving Life Chances For Disabled People,
is about valuing what they can do and what their contribution
can be. I think we need something that matches those two together.
I do not think that is either difficult or impossible but you
have to know that a 25-year old going through this process will
have very different expectations for the rest of his life than
an older person would have and the processes they go through.
This is something that ought to be reflected. This is about that
modernisation.
Q13 Dr Naysmith: What stops that happening
everywhere? You say you have a pilot scheme.
Ms Cox: Around parts of the country
they have begun to do that. I know that certainly in north London
they have used it both for people with a learning disability and
people with mental health problems. There is nothing very specific
in the guidance. The guidance is predominantly around older people,
delayed transfers and so on, and the issues those raise. It would
be helpful if the guidance built on that and picked up where services
are and the direction in which they are going for those individuals
and recognise that the NHS will not be the total provider for
somebody in that age range. They will want a broad spectrum of
services, of which the NHS may be a very important part, but there
will be other elements that will be equally important.
Ms Attlee: I might venture to
disagree. Most of that is absolutely right but we should be making
sure that for older people those principles of promoting independence
and enabling are applied to them, rather than taking a different
approach from that for younger adults. Certainly the evidence
from Age Concern and everyone else is that older people are not
a distinct set of people who suddenly lose all their aspirations.
These are people with a similar range of disabilities, abilities
and aspirations and we should be ensuring that promoting and enabling
approach is across all adults, however old they may be, rather
than taking separate approaches. Certainly in north west London
we have criteria that apply across the board and recognise a huge
amount of dual diagnosis and multi needs that you cannot simply
define as a learning disability or applied to older people or
whatever. We try to encompass all of those across the board.
Q14 Dr Naysmith: What do you think of
that, Ms Cox? That is quite the opposite of what you were arguing.
Ms Cox: It reflects what I said
earlier about learning from other areas. I am hearing that in
north London they have done that to promote independence, choice
and control in terms of valuing people. In learning disability
terms, that is something we have been striving towards for a very
long time. My concern is that we do not go backwards. If what
we are saying is that we want to move forward in the same direction
for all groups, that is a fantastic aspiration to have.
Ms McHale: I would add a little
bit to this part of the debate in that you do not need to go down
separate criteria guidance if you focus on the needs of the individual.
Need should determine the outcome rather than the potential professional
input that is required if there are different service user groups.
You should consider the impact that continuing care could and
should have on children. I firmly believe that if children were
accommodated within the continuing care policy, then you would
see a different long-term commissioning arrangement of service
provision, which would build for the future and contribute to
the aspirations we have around government policy.
Q15 John Austin: For clarification, may
I add to an earlier question from the Chairman that the Chairman
finds it incomprehensible why anybody would move from Wakefield
to Barnsley! I want to come on to the independent review the department
published and the reported response from SHA staff which described
a staggering lack of central guidance. The Ombudsman, in her report,
has said of the guidance that there was a question of misinterpretation
and misapplication. Is it a lack of guidance or is it a lack of
consistency about applying guidance, and could the Department
have done more to ensure a consistency of approach?
Ms McHale: Personally, I think
there have been several attempts at issuing guidance, which have
facilitated the inconsistency in application. One person's interpretation
of complexity or intensity is different from someone else's. I
think more could have been done with regard to clarification and
transparency about the definitions and the applications.
Ms Gilley: One of the issues at
the time, following the publication of Anne Abrahams' first report
on continuing care, was that the Department of Health was not
quick enough. That was our issue in terms of the processes that
we were putting in place in order to try and deal with the numbers
of people who were contacting us, et cetera. That is my comment.
I do not know if there was going to be much that the department
was in a position to do at that time that was going to be helpful
on the criteria themselves. The issue was about helping strategic
health authorities, our primary care trusts and social services
to deal with the numbers of people who were asking for their cases
to be reviewed.
Mr Young: I came new into this
at the same time as the guidance was coming out. I think the guidance
was useful and has improved the consistency. Certainly, having
seen the work done by the predecessor health authorities, the
guidance has already enabled us to improve the consistency of
application and the patient experience of being assessed. Working
towards a national framework with further and more guidance will
support this even more, particularly around the guidance of involving
users and carers in the assessment process and also in understanding
the decisions.
Q16 John Austin: If we go back to the
Ombudsman's recommendations and the review, there has been some
criticism that the Government's action fell short of the Ombudsman's
recommendations. I know my colleague, Dr Naysmith, wants to pursue
this with the next set of witnesses. We have heard a lot about
the postcode lottery and has the review merely reduced the number
of postcodes from 95 to 28?
Ms Gilley: I should not really
be saying this. I do think that over-simplifies things because
it is to do with the assessment process. It is not to do with
28 strategic health authorities, with all due respect, but the
number of primary care trusts and their partners, the social services
departments. In terms of the decision-making process, that is
generally the first and very key stage of that process. It is
about monitoring them and their consistency of decision-making
and making sure that people who are assessing and people who are
deciding are doing that in a consistent and transparent way.
Q17 John Austin: Mr Young has mentioned
the question of the National Framework. Perhaps I could put it
to all of you and ask what that framework should include. Should
it include a complete revision of the eligibility criteria and
should it address both health and personal care issues?
Ms Attlee: It should not be a
complete revision in the sense of starting again. There has been
a huge amount of progress in the criteria that we now work to.
As you say, the 28 health authorities are much closer in their
approach and delivery than the previous 96 were. The review group
is in place and doing that work; it is building on all that good
practice that has happened and the good policy that has been developed.
It is not about a wholesale review but about taking the best and
confirming that as the national standard, which will be very beneficial.
We have certainly developed our policy in conjunction with local
authorities. It is absolutely critical that it covers the whole
spectrum; otherwise it really makes it very difficult to implement
the rest of the policy around integrated services and integrated
care packages for people. That is what we are all about delivering.
Ms McHale: In future, the policy
should concentrate on being transparent, equitable and acceptable.
It certainly should look at how we do things differently, building
on good practice and good examples. It has to be fit for purpose
for the changing services. It is not about just doing exactly
what we have been doing and a bit more of it where it is right.
We have to change to develop the policy so that it reflects how
we want things to work in the future. That does mean encompassing
issues around learning disabilities, direct payments, challenging
behaviours and everything else.
Q18 John Austin: And a consistency of
approach on assessment procedures?
Ms McHale: There should be a consistency
of approach on assessment procedures and ownership of continuing
care. We talked about the 28 strategic health authorities but
the PCTs have to own this as well. It should not be resource-driven.
There is a huge element of resource availability that relates
to interpretation of eligibility.
Q19 John Austin: I assume that organisations
like the ADSS are in continuing negotiation or consultation with
the department over this?
Ms McHale: We have been invited
to participate in the revision and we are very pleased about that.
We would like to be partners in it and not just required to sign
up to agreements.
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